New Patient Application

DeLand Chiropractic & Spinal Decompression New Patient Application The information that you will provide on this form will play a key role in determining your ability to be accepted as a patient in this office. Your qualification as a patient is determined by the nature of your injury, the doctor’s ability to treat your condition, your commitment to getting well, your family and/or spousal support, your ability to pay for recommended care, and your willingness to make sacrifices to ensure your proper healing. Please be sure that you answer all questions. Thank you – Dr. Gordon’s Staff. Name: _________________________________________ Sex: M F Marital Status: S M D W Address: ________________________________________________ City:______________________ State: _______ Zip Code: _____________ Date of Birth: __________ SSN: ____________________ Home Phone: ________________ Work Phone: _________________ Cell Phone:_______________ Employer: _____________________________ Occupation: _________________________________ Age:_________ Email:________________________________ Hobbies:_______________________ Name Of Your Medical Doctor And May We Contact Them?:__________________________ Y N Race: _____________________ Ethnicity: ____________________ Are Your Pregnant? Y N How Did You Hear About Our Clinic: _______________________ Preferred Language:_________ Emergency Contact Name & Phone #: _______________________________ Relation:___________ ------------------------------------------------------------------------------------------------------------------------------ What Is Your Chief Complaint? _______________________________________________________ ___________________________________________________________________________________ Date Of Your Injury? ________________ Work Related? Y N Auto Accident Related? Y N Have Had Chiropractic Care Before? Y N How About Acupuncture? Y N ------------------------------------------------------------------------------------------------------------------------------ Do You Smoke Cigarettes? Y N Currently? Y N Formerly? Y N Never? Do You Drink Alcohol? Y N If Yes, How Often?____________ How Much? _____________ Do You Use Recreational Drugs? Y N What Type?_________________________________ ------------------------------------------------------------------------------------------------------------------------------ Do You Have A Family History Of: (check all that apply) Heart Disease Arthritis Hypothyroid Diabetes ( Type I Type II) Seizures Stroke Osteoporosis Rare Genetic Disease (type) ___________________________ Cancer (type) _______________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------ Do You Have A Past Medical History Of: (check all that apply) Lower Back Pain Stroke Thyroid Disease Diabetes ( Type I II) Sciatic Pain Birth Control Pills Auto Accidents Hormone Replacement Hypertension Head Trauma Heart Attack Osteoporosis Neck / Back Trauma Blood Clots Balance Problems Dizziness Cancer (type)_____________________________ Numbness On ½ Of Your Face or Body Please List Any Allergies, Surgeries, Accidents, Falls, Pregnancies, Or Hospitalizations: _____________________________________________________________________________________ _____________________________________________________________________________________ List All Medications & Dietary Supplements That You Are Taking (List Dosage & Frequency): ________________________________________ __________________________________________ ________________________________________ __________________________________________ ________________________________________ __________________________________________ ________________________________________ __________________________________________ ________________________________________ __________________________________________ -------------------------------------------------------------------------------------------------------------------------------- If the doctor recommends a treatment plan to correct or manage your condition, are you willing to make small sacrifices (changing diet, exercise, change habits) in order to receive care in our office? Yes No If your health insurance (if applicable) does not cover 100% of your proposed care, are you willing to make a personal financial investment in your own health in order to get well and improve your health? Yes No IF YOU HAVE ANY QUESTIONS OR CONCERNS WITH THE INFORMATION BELOW, IT IS YOUR RESPONSIBILITY TO ADDRESS THOSE CONCERNS WITH THE DOCTOR. Informed Consent, Financial Responsibility, and Assignment of Benefits: As with all medical or chiropractic treatments, I acknowledge and understand that there are inherent risks to receiving care including but not limited to sprains, strains, fractures, dislocations, muscle pain, bruising, and stroke. Statistically, these risks are extremely rare and uncommon (1 in 1 – 5 million in the case of strokes), especially when compared to those risks related with alternative treatment options for my condition including the use of over the counter analgesics, prescription drugs, and surgery. Due to that fact, I will not hold the physician or staff responsible for those risks listed above. In addition, I understand that the risk and danger of allowing my condition to go untreated may lead to further deterioration of my condition with possible serious and/or permanent consequences to my health. I acknowledge and understand that the use of certain prescription medications (i.e. birth control pills, hormone replacement, aspirin, Coumadin), illicit drug or alcohol use, and cigarette smoking may increase these risks and inhibit proper healing. I also understand that if I am accepted as a patient, and if I receive care, that I am the ultimate responsible party on my account regardless of the actions of any 3rd party carrier (insurance company). I agree that should my account become delinquent, I will be responsible for all collection costs, including but not limited to the outstanding balance, attorney fees, court costs, collection agency fees, and interest at the rate of 18% per annum(1.5% per month). By signing below, I also agree to allow the doctor to share any and all medial reports and findings with my primary care physician, and I allow the doctor to use my name and case history in monthly newsletters and/or patient testimonial booklets. Lastly I understand that any physician at DeLand Chiropractic & Spinal Decompression can not evaluate, examine, x-ray, diagnose, or treat me for my presenting condition without my signature below. By signing below I acknowledge that I have weighed the risks versus benefits of treatment, and I give the doctor consent to treat me for my condition. Print Name:__________________________________________ Date:____________________________ Signature: ___________________________________________ Name: _____________________________________________________ Date: _____________________ Auto Accident Details: 1. Were you the □ driver □ front seat passenger □ rear seat passenger □ motorcycle rider 2. The make of the vehicle that you were in during the accident was a _______________________________ 3. The make of the other vehicle involved in the accident was a ____________________________________ 4. Your estimated speed at the time of the accident was __________________________________________ 5. The time of day of the accident was □ daytime □ dawn □ dusk □ dark 6. Road conditions at the time of the accident were □ dry □ wet □ snow □ ice 7. Were you wearing a seatbelt at the time of the accident? □ yes □ no Did an airbag deploy? □ yes □ no 8. Was your head turned at the time of the accident? □ yes □ no 9. If you were the driver, was your foot applied on the brake at the time of the accident? □ yes □ no 10. Did you strike any part of the interior of the vehicle during the accident? □ yes □ no 11. Did you lose consciousness as a result of the accident? □ yes □ no If yes, how long? ______________ 12. Was a police report made at the accident scene? □ yes □ no Who was found to be “at fault”? ________ 13. Estimated property damage to your vehicle __________________________________________________ 14. After the crash did you go □ home □ emergency room. Mode of transportation? ___________________ 15. What were your primary symptoms after the accident? _________________________________________ 16. Have you seen any other physicians or received treatment for your injuries anywhere else? □ yes □ no If yes, where? ______________________________________________________________________ 17. Please describe and diagram your accident below: Please mark the figures below with the letters that best describe the sensation or pain you are feeling. Please mark areas where pain radiates or spreads with a ↑, ↓, or ←, → arrow to indicate the direction of radiating pain. (Include all affected areas) >>> Ache XXX Burning - - - - Throbbing === Numbness /////// Stabbing oooo Pins & Needles Severity of Pain List region of pain and circle severity (1=least, 10=greatest) 1._______________________ 1 2 3 4 5 6 7 8 9 10 2._______________________ 1 2 3 4 5 6 7 8 9 10 3._______________________ 1 2 3 4 5 6 7 8 9 10 4._______________________ 1 2 3 4 5 6 7 8 9 10 Name__________________________________________ Date ___________________ Instrumental Activities of Daily Living Scale (I.A.D.L.) Choose the option below that best describes your ability: 1. Ability to use the telephone: 2. Laundry: a. Operates telephone

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